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Recurrence of Herpetic Stromal Keratitis After a Conjunctival Flap Surgical Procedure
Vol. 114, No. 2
Letters to The Journal
On the next day, the right eye also exhibit ed a serofibrinous iritis. Further examination showed an increased body temperature of 38.4 C, an accelerated Westergren erythrocyte sedi mentation rate (60 mm after one hour, 130 mm after two hours), a leukocytosis of 13,800 cells/ mm3, a decreased hemoglobin concentration of 5.5 m g / d l , an increased creatinine level of 3.4 mg/dl, and proteinuria. Case 2 A 37-year-old woman with redness in both eyes was referred to us. Two days earlier she had noticed a sudden appearance of erythematous nodules and plaques on her face, neck, and arms. Two weeks previously, she had suffered from pyelonephritis. One month before that, she had had several bouts of intestinal colic. With the exception of a bilateral nasal episcleritis, no other ophthalmic abnormality was de tected. Further medical examination showed an increased body temperature of 38 C, a leukocy tosis of 20,300 cells/mm 3 , an accelerated eryth rocyte sedimentation rate of 110 m m / h r after the first hour, and an increased creatinine level of 4.6 m g / d l . Examination of skin biopsy specimens from both patients disclosed dense neutrophilic perivascular infiltration of the dermis without evidence of vasculitis. Both patients were treat ed with systemic corticosteroids starting with a daily dosage of 120 mg and 80 mg of prednisolone, respectively. Dosage was continuously reduced within two weeks. Additionally, mydriatics and corticosteroids were applied topical ly. After one to two weeks, the skin and ocular symptoms had almost completely disappeared, with visual acuity restored to 20/20 in both eyes of both patients and a decreased erythro cyte sedimentation rate. The appearance of acute erythematous pain ful nodules and plaques and the prevailing neutrophilic infiltration of the skin without clinical signs of vasculitis were the major crite ria for diagnosis of Sweet's syndrome in our patients. The occurrence of at least two of the five minor criteria for Sweet's syndrome (pro dromal symptoms; increased body tempera ture, arthralgia, conjunctivitis, and neoplasms; increased erythrocyte sedimentation rate; leu kocytosis; and fast remission with corticosteroid treatment, with no effect of antibiotics) 3 also led to the diagnosis of Sweet's syndrome in both patients. Because of some overlap in the symptoms, Behçet's syndrome should be con sidered as part of the differential diagnosis.
231
Because Sweet's syndrome can be associated with malignancies and systemic inflammato ry disorders, it should be diagnostically ex cluded in patients who have ocular inflammato ry symptoms and erythematous nodules, and plaques on the face, neck, and extremities at initial examination.
References 1. Gunawardena, D. A., Gunawardena, K. A., Ratnayaka, R. M. R. S., and Vasanthanathan, N. S.: The clinical spectrum of Sweet's syndrome (acute febrile neutrophilic dermatosis). A report of eighteen cases. Br. J. Dermatol. 92:363, 1975. 2. Fourman, S.: Inflammatory glaucoma associated with Sweet's syndrome. Am. J. Ophthalmol. 105:691, 1989. 3. von den Driesch, P., Schlegel-Gomez, R., Kiesewetter, F., and Hornstein, O. P.: Sweet's syn drome. Clinical spectrum and associated conditions. Cutis 44:193, 1989.
Recurrence of Herpetic Stromal Keratitis After a Conjunctival Flap Surgical Procedure Mark P. Lesher, M.D., Lawrence E. Lohman, M . D . , W i l l i a m Yeakley, M.D., and Jonathan Lass, M . D . Department of Ophthalmology, University Hospitals of Cleveland and Case Western Reserve University. Inquiries to Jonathan Lass, M.D., Department of Ophthalmology, University Hospitals of Cleveland and Case Western Reserve University, 2074 Abington Rd., Cleveland, OH 44106. The use of the conjunctival flap surgical pro cedure in the treatment of persistent, epithelial defects or corneal ulcération secondary to her pes simplex keratitis has been well described. 13 Conjunctival flaps are typically reserved for those cases that have been unresponsive to treatment with lubricants, bandage lenses, or tarsorrhaphy. 4 The Gunderson flap surgical procedure and modifications have been effec tive in the treatment of persistent epithelial defects and stromal ulcération in most cases with resulting stabilization and resolution of the inflammatory process. 1 We treated two pa-
232
August, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
tients with corneal ulcération secondary to her pes simplex keratitis with the conjunctival flap surgical procedure. The herpetic stromal dis ease subsequently recurred beneath the flap, and in one case led to corneal perforation. Case 1 A 79-year-old man with a three-month histo ry of herpes simplex keratitis was referred for a persistent epithelial defect of the right eye. His medical history indicated chronic obstructive pulmonary disease, hypertension, and radia tion treatment for prostate cancer. The epitheli al defect was not associated with stromal infil tration and persisted despite intensive treatment with topical lubricants and lateral tarsorrhaphy. He underwent an uncomplicated total conjunctival flap procedure. Two months postoperatively, a dense infiltrate was noted in the area of the previous epithelial defect (Fig. 1). The infiltrate subsequently resolved with topical trifluridine 1% treatment and a tapered treatment course of prednisolone acetate Vs% with no recurrence of the herpes simplex kerati tis one year postoperatively. Case 2 A 72-year-old woman with a medical history of hypertension, seizure disorder, and recur rent herpes simplex keratitis for more than 40 years developed a persistent epithelial defect of the right eye after treatment of a secondary keratitis caused by Pseudomonas organisms. The epithelial defect persisted despite aggres sive treatment with topical lubricants. One month after referral, she underwent an uncom plicated total conjunctival flap procedure. Six
Fig. 2 (Lesher and associates). Case 2. Histologie section of host corneal button demonstrates the per foration site and adjacent areas of lymphocyte and plasma cell infiltration (hematoxylin and eosin, x 140). months later, the patient developed several areas of active stromal inflammation beneath the flap, which ultimately led to corneal perfo ration (Fig. 2). Penetrating keratoplasty and cataract extraction with intraocular lens im plantation were performed. Her graft has re mained clear with no recurrence of herpes sim plex keratitis at one year postoperatively. The conjunctival flap surgical procedure has been considered the definitive treatment for persistent epithelial defects or nonhealing cor neal ulcération secondary to herpes simplex keratitis that is unresponsive to medical treat ment or tarsorrhaphy. In one series of nine patients who underwent a conjunctival flap surgical procedure for herpes simplex keratitis, none developed recurrence of active superficial or deep inflammation for a follow-up period of one to six years. 1 We can only speculate as to the reasons for recurrence in our two patients. The age and general debility of our patients may have contributed to a recurrence of active viral disease or immune-mediated stromal keratitis, or both. Patients with herpes simplex keratitis after a conjunctival flap surgical procedure should be carefully observed to monitor for recurring active stromal disease.
References
Fig. 1 (Lesher and associates). Case 1. Slit-lamp photograph of cornea in the right eye after the conjunctival flap surgical procedure. Note the dense stromal infiltration beneath the flap (arrow).
1. Brown, D. B., McCulley, J. P., Bowman, R. W., and Halsted, M. A.: The use of conjunctival flaps in treatment of keratouveitis. Cornea 11:44, 1992. 2. Portnoy, S. L., Insler, M. S., and Kaufman, H. E.: Surgical management of corneal ulcération and perforation. Surv. Ophthalmol. 34:47, 1989.
Vol. 114, No. 2
Letters to The Journal
3. Reinhart, W. ].: Conjunctival flap surgery. In Bruner, W. E., Stark, W. ]., and Maumenee, A. E. (eds.): Manual of Corneal Surgery. New York, Churchill-Livingstone, 1987, pp. 63-77. 4. Mannis, M. J.: Conjunctival flaps. Int. Ophthalmol. Clin. 28:165, 1988.
Enterococcus faecalis Infection in a Corneal Graft Mark D. Sherman, M.D., H. Bruce Ostler, M.D., Roderick Biswell, M.D., and Vicky Cevallos, M.T.(A.S.C.P.) Francis I. Proctor Foundation, University of Califor nia at San Francisco. Inquiries to Mark D. Sherman, M.D., Proctor Foundation, Room S315, University of California, San Francisco, CA 94143-0412. Enterococcus faecalis can cause serious sys temic infections, including bacteremia, endo carditis, and intra-abdominal sepsis. This gram-positive organism, which was previously classified as a group D streptococcus, can devel op both intrinsic and acquired resistance to multiple antimicrobial agents. 1 As an ocular pathogen, E. faecalis is best known as a cause of endophthalmitis, 2 whereas isolation of E. faecalis from corneal specimens has been re ported only infrequently. Corneal infection with this organism has been described as induc ing a "rapid and severe inflammatory re sponse" that can be devastating to the eye. 8
233
A 61-year-old man with a history of recurrent herpes simplex keratouveitis in the right eye was referred to our institution for examination of a persistent epithelial defect and an underly ing stromal infiltrate of three weeks' duration (Fig. 1). He had undergone a second penetrat ing keratoplasty nine months earlier. At exami nation, he was wearing a bandage contact lens, and he was using topical chloramphenicol six times daily, prednisolone acetate three times daily, timolol maleate 0.5% twice daily, and echothiophate iodide twice daily. He was also using methazolamide, 25 mg, twice daily. Examination of the left eye disclosed no ab normalities and his visual acuity was 20/20. His best-corrected visualacuity in the right eye was 20/400. The intraocular pressure was 16 mm Hg. Slit-lamp examination disclosed an irregular epithelial surface overlying a paracentral focal anterior stromal infiltrate (2 mm in diameter) with short discrete feathery mar gins.There was diffuse stromal edema and folds in Descemet's membrane. There were no under lying keratic precipitates, and there were no inflammatory cells in the anterior chamber. Examination of corneal scrapings demonstrated many gram-positive cocci in pairs and short chains with a few polymorphonuclear leuko cytes (Fig. 2). We empirically treated the patient with vancomycin (50 m g / m l every hour) pend ing definitive identification of the organism and results of sensitivity testing. We discontinued treatment with chloramphenicol and removed the contact lens. The organism was identified as £. faecalis and was resistant to cephalothin, and tobramycin. It
'
« i r : **·% . ♦ ' ,
. * r * a»
Fig. 1 (Sherman and associates). Slit-lamp photo graph of patient's right eye at initial examination.
Fig. 2 (Sherman and associates). Gram stain dem onstrating multiple gram-positive cocci in short chains.
Letters to The Journal
On the next day, the right eye also exhibit ed a serofibrinous iritis. Further examination showed an increased body temperature of 38.4 C, an accelerated Westergren erythrocyte sedi mentation rate (60 mm after one hour, 130 mm after two hours), a leukocytosis of 13,800 cells/ mm3, a decreased hemoglobin concentration of 5.5 m g / d l , an increased creatinine level of 3.4 mg/dl, and proteinuria. Case 2 A 37-year-old woman with redness in both eyes was referred to us. Two days earlier she had noticed a sudden appearance of erythematous nodules and plaques on her face, neck, and arms. Two weeks previously, she had suffered from pyelonephritis. One month before that, she had had several bouts of intestinal colic. With the exception of a bilateral nasal episcleritis, no other ophthalmic abnormality was de tected. Further medical examination showed an increased body temperature of 38 C, a leukocy tosis of 20,300 cells/mm 3 , an accelerated eryth rocyte sedimentation rate of 110 m m / h r after the first hour, and an increased creatinine level of 4.6 m g / d l . Examination of skin biopsy specimens from both patients disclosed dense neutrophilic perivascular infiltration of the dermis without evidence of vasculitis. Both patients were treat ed with systemic corticosteroids starting with a daily dosage of 120 mg and 80 mg of prednisolone, respectively. Dosage was continuously reduced within two weeks. Additionally, mydriatics and corticosteroids were applied topical ly. After one to two weeks, the skin and ocular symptoms had almost completely disappeared, with visual acuity restored to 20/20 in both eyes of both patients and a decreased erythro cyte sedimentation rate. The appearance of acute erythematous pain ful nodules and plaques and the prevailing neutrophilic infiltration of the skin without clinical signs of vasculitis were the major crite ria for diagnosis of Sweet's syndrome in our patients. The occurrence of at least two of the five minor criteria for Sweet's syndrome (pro dromal symptoms; increased body tempera ture, arthralgia, conjunctivitis, and neoplasms; increased erythrocyte sedimentation rate; leu kocytosis; and fast remission with corticosteroid treatment, with no effect of antibiotics) 3 also led to the diagnosis of Sweet's syndrome in both patients. Because of some overlap in the symptoms, Behçet's syndrome should be con sidered as part of the differential diagnosis.
231
Because Sweet's syndrome can be associated with malignancies and systemic inflammato ry disorders, it should be diagnostically ex cluded in patients who have ocular inflammato ry symptoms and erythematous nodules, and plaques on the face, neck, and extremities at initial examination.
References 1. Gunawardena, D. A., Gunawardena, K. A., Ratnayaka, R. M. R. S., and Vasanthanathan, N. S.: The clinical spectrum of Sweet's syndrome (acute febrile neutrophilic dermatosis). A report of eighteen cases. Br. J. Dermatol. 92:363, 1975. 2. Fourman, S.: Inflammatory glaucoma associated with Sweet's syndrome. Am. J. Ophthalmol. 105:691, 1989. 3. von den Driesch, P., Schlegel-Gomez, R., Kiesewetter, F., and Hornstein, O. P.: Sweet's syn drome. Clinical spectrum and associated conditions. Cutis 44:193, 1989.
Recurrence of Herpetic Stromal Keratitis After a Conjunctival Flap Surgical Procedure Mark P. Lesher, M.D., Lawrence E. Lohman, M . D . , W i l l i a m Yeakley, M.D., and Jonathan Lass, M . D . Department of Ophthalmology, University Hospitals of Cleveland and Case Western Reserve University. Inquiries to Jonathan Lass, M.D., Department of Ophthalmology, University Hospitals of Cleveland and Case Western Reserve University, 2074 Abington Rd., Cleveland, OH 44106. The use of the conjunctival flap surgical pro cedure in the treatment of persistent, epithelial defects or corneal ulcération secondary to her pes simplex keratitis has been well described. 13 Conjunctival flaps are typically reserved for those cases that have been unresponsive to treatment with lubricants, bandage lenses, or tarsorrhaphy. 4 The Gunderson flap surgical procedure and modifications have been effec tive in the treatment of persistent epithelial defects and stromal ulcération in most cases with resulting stabilization and resolution of the inflammatory process. 1 We treated two pa-
232
August, 1992
AMERICAN JOURNAL OF OPHTHALMOLOGY
tients with corneal ulcération secondary to her pes simplex keratitis with the conjunctival flap surgical procedure. The herpetic stromal dis ease subsequently recurred beneath the flap, and in one case led to corneal perforation. Case 1 A 79-year-old man with a three-month histo ry of herpes simplex keratitis was referred for a persistent epithelial defect of the right eye. His medical history indicated chronic obstructive pulmonary disease, hypertension, and radia tion treatment for prostate cancer. The epitheli al defect was not associated with stromal infil tration and persisted despite intensive treatment with topical lubricants and lateral tarsorrhaphy. He underwent an uncomplicated total conjunctival flap procedure. Two months postoperatively, a dense infiltrate was noted in the area of the previous epithelial defect (Fig. 1). The infiltrate subsequently resolved with topical trifluridine 1% treatment and a tapered treatment course of prednisolone acetate Vs% with no recurrence of the herpes simplex kerati tis one year postoperatively. Case 2 A 72-year-old woman with a medical history of hypertension, seizure disorder, and recur rent herpes simplex keratitis for more than 40 years developed a persistent epithelial defect of the right eye after treatment of a secondary keratitis caused by Pseudomonas organisms. The epithelial defect persisted despite aggres sive treatment with topical lubricants. One month after referral, she underwent an uncom plicated total conjunctival flap procedure. Six
Fig. 2 (Lesher and associates). Case 2. Histologie section of host corneal button demonstrates the per foration site and adjacent areas of lymphocyte and plasma cell infiltration (hematoxylin and eosin, x 140). months later, the patient developed several areas of active stromal inflammation beneath the flap, which ultimately led to corneal perfo ration (Fig. 2). Penetrating keratoplasty and cataract extraction with intraocular lens im plantation were performed. Her graft has re mained clear with no recurrence of herpes sim plex keratitis at one year postoperatively. The conjunctival flap surgical procedure has been considered the definitive treatment for persistent epithelial defects or nonhealing cor neal ulcération secondary to herpes simplex keratitis that is unresponsive to medical treat ment or tarsorrhaphy. In one series of nine patients who underwent a conjunctival flap surgical procedure for herpes simplex keratitis, none developed recurrence of active superficial or deep inflammation for a follow-up period of one to six years. 1 We can only speculate as to the reasons for recurrence in our two patients. The age and general debility of our patients may have contributed to a recurrence of active viral disease or immune-mediated stromal keratitis, or both. Patients with herpes simplex keratitis after a conjunctival flap surgical procedure should be carefully observed to monitor for recurring active stromal disease.
References
Fig. 1 (Lesher and associates). Case 1. Slit-lamp photograph of cornea in the right eye after the conjunctival flap surgical procedure. Note the dense stromal infiltration beneath the flap (arrow).
1. Brown, D. B., McCulley, J. P., Bowman, R. W., and Halsted, M. A.: The use of conjunctival flaps in treatment of keratouveitis. Cornea 11:44, 1992. 2. Portnoy, S. L., Insler, M. S., and Kaufman, H. E.: Surgical management of corneal ulcération and perforation. Surv. Ophthalmol. 34:47, 1989.
Vol. 114, No. 2
Letters to The Journal
3. Reinhart, W. ].: Conjunctival flap surgery. In Bruner, W. E., Stark, W. ]., and Maumenee, A. E. (eds.): Manual of Corneal Surgery. New York, Churchill-Livingstone, 1987, pp. 63-77. 4. Mannis, M. J.: Conjunctival flaps. Int. Ophthalmol. Clin. 28:165, 1988.
Enterococcus faecalis Infection in a Corneal Graft Mark D. Sherman, M.D., H. Bruce Ostler, M.D., Roderick Biswell, M.D., and Vicky Cevallos, M.T.(A.S.C.P.) Francis I. Proctor Foundation, University of Califor nia at San Francisco. Inquiries to Mark D. Sherman, M.D., Proctor Foundation, Room S315, University of California, San Francisco, CA 94143-0412. Enterococcus faecalis can cause serious sys temic infections, including bacteremia, endo carditis, and intra-abdominal sepsis. This gram-positive organism, which was previously classified as a group D streptococcus, can devel op both intrinsic and acquired resistance to multiple antimicrobial agents. 1 As an ocular pathogen, E. faecalis is best known as a cause of endophthalmitis, 2 whereas isolation of E. faecalis from corneal specimens has been re ported only infrequently. Corneal infection with this organism has been described as induc ing a "rapid and severe inflammatory re sponse" that can be devastating to the eye. 8
233
A 61-year-old man with a history of recurrent herpes simplex keratouveitis in the right eye was referred to our institution for examination of a persistent epithelial defect and an underly ing stromal infiltrate of three weeks' duration (Fig. 1). He had undergone a second penetrat ing keratoplasty nine months earlier. At exami nation, he was wearing a bandage contact lens, and he was using topical chloramphenicol six times daily, prednisolone acetate three times daily, timolol maleate 0.5% twice daily, and echothiophate iodide twice daily. He was also using methazolamide, 25 mg, twice daily. Examination of the left eye disclosed no ab normalities and his visual acuity was 20/20. His best-corrected visualacuity in the right eye was 20/400. The intraocular pressure was 16 mm Hg. Slit-lamp examination disclosed an irregular epithelial surface overlying a paracentral focal anterior stromal infiltrate (2 mm in diameter) with short discrete feathery mar gins.There was diffuse stromal edema and folds in Descemet's membrane. There were no under lying keratic precipitates, and there were no inflammatory cells in the anterior chamber. Examination of corneal scrapings demonstrated many gram-positive cocci in pairs and short chains with a few polymorphonuclear leuko cytes (Fig. 2). We empirically treated the patient with vancomycin (50 m g / m l every hour) pend ing definitive identification of the organism and results of sensitivity testing. We discontinued treatment with chloramphenicol and removed the contact lens. The organism was identified as £. faecalis and was resistant to cephalothin, and tobramycin. It
'
« i r : **·% . ♦ ' ,
. * r * a»
Fig. 1 (Sherman and associates). Slit-lamp photo graph of patient's right eye at initial examination.
Fig. 2 (Sherman and associates). Gram stain dem onstrating multiple gram-positive cocci in short chains.